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IMPORTANT: You will not be able to save and return to this page if incomplete. Please make sure that you enter all of the information for ALL the required fields. Documents must be on file at the school before entering.

Please provide the following information:

*All fields are required.

Student Last Name
Student Middle Initial
Student First Name
School
Other:
Student Email
Student Phone
Student Last 4 Digits of Social Security
Student Date of Birth
School Instructor Last Name
School Instructor First Name
School Instructor Email
School Instructor Phone Number
Start Date
End Date
Total Clinical Hours
Please estimate clinical hours if you do not
know exact hours.
Is student a prior or current CSM employee, volunteer or student?
Type of Student
Other:
Location
Other:
Department
Other:

Student Confirmation:

The student listed here is in compliance with the contractual health policies of the Clinical Education Setting including, but not limited to,
certifying that prior to reporting to the Clinical Education Setting each has:
I verify this to be true

 

  • Physical exam which indicates he/she is free from communicable disease, able to meet physical demands of the work indicating any ADA accommodations, health history with signed declaration by student that the report is correct to the best of their knowledge, and annual declaration by student that health status is unchanged to the best of their knowledge,
  • He/she is free from active tuberculosis as documented by a negative Mantoux skin test or negative chest x-ray (dated after skin test conversion)and is free from signs and symptoms of tuberculosis. Quantiferon TB test acceptable in lieu of annual Mantoux skin test,
  • Documented immunity to Rubella, Rubeola, and Mumps (MMR); positive titer or medical documentation of 2 MMRs, 1 month apart, with the 1st dose after the first birthday, and the 2nd dose at least 1 month thereafter,
  • Documented immunity to Varicella, positive titer or doses of varicella vaccine 4 weeks apart.
  • Have been advised of the risks of Hepatitis B and have either begun the Hepatitis B vaccination series or, in the alternative, have completed the appropriate declination of immunization form.
  • Have received seasonal influenza vaccine each year no later than October 31st. (For student experiences taking place between September 1st and March 31st)
    **Please Note: Any reason other than medical contraindication the student will not be permitted to participate in a clinical experience. The academic partner is to track student compliance with this requirement and send statistical documentation of the same to the designated Columbia St. Mary’s education contact. This documentation should include total number of students attending a CSM facility, how many had a documented medical contraindication to the vaccine. Medical Declination form shall be on file at the education setting.

    ** Please Note: Students/Instructors with exemptions to the vaccine are required to wear a surgical mask during the influenza season whenever in buildings where patient care takes place, regardless of whether the student/instructor is a direct caregiver or not.
  • A negative 10 panel urine drug screen. If positive, he/she will not be permitted to participate in a clinical placement. Notice of this is provided to the Clinical Education Setting.

 

I verify this to be true

The student listed has had a background check performed under the direction of the institution in accordance with the Wisconsin Caregiver Background Check Law and Does not have any adult criminal arrests with convictions or any currently pending charges.

I verify this to be true

The student listed here is in compliance with the contractual health policies of the Clinical Education Setting including, but not limited to
The student listed here DOES have a criminal record on file or currently pending charges. A copy of their completed Disclosure Form and criminal record report will be forwarded to the CSM Student Coordinator no less than 2 weeks prior to the start of the clinical experience. (If a student has been arrested for criminal code 940.19, 940.195, 940.20, 941.30, 942.08, 947.01 or 947.013 within the last 5 years, a copy of the criminal complaint and judgement of conviction must accompany the record.)

I verify this to be true

The student listed is certified in American Heart Association, Health Care Provider, Basic Life Support.

I verify this to be true

Check here if this student does not require CPR/BLS certification (Will have no patient interaction)

I verify this to be true

The Student Compliance Checklist is on file at the school.

I verify this to be true

The Student Confidentiality Agreement is on file at the school.

I verify this to be true

Student has completed Department Orientation.

I verify compliance for this student and confirm that the required documents are on file at the school and are available upon request.
School Coordinator Name
Date
 

Columbia St. Mary's

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